educational solutions for workforce development pharmacy significant event analysis fiona mcmillan...
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Educational Solutions for Workforce Development
Pharmacy
Significant Event Analysis
Fiona McMillanLead Pharmacist Educational Development
Aim
To advise on development of a process for the analysis of Significant Events to promote learning and reflection within your team
‘To err is human, to cover up is unforgivable and to fail to learn is
inexcusable’’
Liam Donaldson 2004
Background
• SEA embedded medical model
• Effective analysis allows reflection and learning within the team
• Positive and negative events
• Safe and effective medicines management needs systems to ensure that patient safety is maintained.
• Sharing practice aids development of good practice.
Educational Solutions for Workforce Development
PharmacyWhat is a Significant Event?
“Any event thought by anyone in the health care team to be significant in the care of patients or the conduct of the practice ororganisation.’
Pringle et al, 1995
Examples of Significant Events
Wrong drug prescribed
Wrong drug dispensed
Patient complaints
IT issue leading to error
Drug interaction not noted
Medication labelled incorrectly
Lack of communication within healthcare team
Issues with training
What is the process for analysis and receiving peer comments?
Complete
SEA
proforma
Discuss
at peer review +
include all involved
Update
Submit to NES
Feedback
Share again with peers
Questions in SEA form
What happened? Give adequate detail to enable reviewers to understand the whole picture
Why did it happen?Explain reasons from your analysis
What have you learned?Can be a list
What have you changed?Will this prevent reoccurrence
Benefits of SEA
Peer
reviewers
Peer review
Recording and
discussion with peers
Individual
analysis
Joint
Learning
+
improved patient
care
Educational Solutions for Workforce Development
Pharmacy
•What benefits do you see?
•What are your next steps?
How could you integrate this into your practice?